Do you have any thoughts on work comp office notes being released to the patient via electronic chart systems (i.e. MyChart)? Our health system moved our Occ Med practice to Epic unfortunately, and recently changed the settings so patients are receiving Work Comp visit notes. Historically, these notes have not been shared to the patients.
This conversation started out with the very familiar issues many of our health system affiliated occmed practices experience moving to system-wide EHRs.
On the surface, the question is about who owns the occupational health medical record and has access to the chart.
But we’ll peel this down to the core issue in just a bit…
Although patients may always have access to their medical records, the fact that your Occ health EHR didn’t have a patient “portal” doesn’t mean they couldn’t view their notes; it just wasn’t as convenient for them.
I queried why the practice is not wanting to share the records with patients.
I’m more concerned when notes are sent out of Epic to an employer and they contain PHI that would not have been in an occmed EHR – PMH, PFSH, meds not related to work comp cases, etc.
The answer opened a different conversation entirely. One that we’ve been increasingly aware of the “hidden” impact on delayed recovery in workers compensation.
I believe the primary concern is when patients have immediate access to the work comp note via Epic MyChart and they don’t like what was documented, the follow-up visits can become challenging/contentious.
I initially thought the issue here was more about communicating with the patient regarding their care plan and return-to-work plan, including any modified duty restrictions or job transfer. There shouldn’t be any surprises in the medical record that the patient was unaware of.
However, requesting examples of when/how this has happened and how it resulted in the challenging/contentious situation started down the true path of “enlightenment.”
The medical director lamented:
I think the issue revolves around difficult patients who have confounding histories and/or non-physiologic findings. I always try to document what the patient tells me, what their employer may tell me, exaggerated pain behaviors, etc. When they return for f/u they want to contest all of those findings. You can’t rationalize with an irrational patient. For them to see the documentation in real-time creates controversy.
Work Comp Medical Record
For the moment, addressing just the medical record documentation issues, there’s not much recourse to not making the medical record available to the patient, whether through Mychart or by request in any other system.
Documenting what you are told by the patient and the employer is just that, documentation. There’s nothing to contest if it just documenting what you heard/read.
Exaggerated pain behavior is better stated as “tenderness/pain on palpation/ pain with ROM beyond what is expected for the injury described/diagnosed.” There’s nothing judgemental here, just not what you expected.
Keeping the work restrictions/modifications to what can be done safely according to functional assessment of strength and ROM is something that can be demonstrated to the patient and acknowledged by them to RTW.
I would just make sure the record is stated as objectively as possible, focused on activity prescriptions based on functional ability vs. subjective complaints, and thus minimize what a patient could really object to in the first place.
The Root Cause of DFRUD
However, the “hidden” issue is at the root of most if not all of the “DFRUD” cases – Delayed or Failed Recovery and Unnecessary Disability – biopsychosocial determinants of health affecting these “difficult patients,” the ones that don’t progress as expected or put up complaints and barriers to recovery.
In part 2 of our “Fit For Duty” podcast discussion on Delayed Recovery in Workers Comp with Diana Kraemer, MD, neurosurgeon and immediate past president of IAIME – the International Academy of Independent Medical Evaluators, she counsels the patient:
Yes, it hurts. It’s safe. We’ve checked … you don’t have a, you are not going to hurt yourself by work, by moving.
For chronic pain patients:
we’re not going to cure your pain. We’re going to reduce your pain and we’re going to focus on function.
On the biopsychosocial model:
recognize the worker at risk for delay in recovery. Integrate the psychosocial context at the beginning of our treatment … embracing the biopsychosocial model, which is intrinsically supportive, and helps our identity as physicians.
Delayed Recovery Part 2 – Risk Assessment & Interventions
Even the medical director in the above scenario admitted:
I actually just presented at a local W/C conference regarding difficult patients and my recommendation was to throw out the biomedical model and adopt the biopsychosocial model if you expect to have any success
BioPsychoSocial Model
The biopsychosocial model considers a variety of factors beyond just physical symptoms. In workers’ compensation cases, these determinants can significantly influence recovery. Some of the most common biopsychosocial determinants include:
- Psychological Factors:
- Fear-Avoidance Beliefs: Fear of pain or re-injury can lead to avoidance of activities, which may impede recovery.
- Catastrophizing: Exaggeration or irrational thought processes about pain and injury can affect progress.
- Depression and Anxiety: Mental health conditions can contribute to slower recovery and influence pain perception.
- Social Factors:
- Workplace Environment: Lack of employer support or conflicts at the workplace can deter recovery.
- Social Support: Insufficient support from family or friends can impact the emotional and psychological well-being, crucial for recovery.
- Socioeconomic Status: Limited financial resources can exacerbate stress and impact access to medical care.
- Cultural Beliefs and Attitudes:
- Different cultural perceptions of illness and injury can influence how individuals cope and respond to treatment.
- Personal Factors:
- Coping Mechanisms: Ineffective coping strategies can prolong disability.
- Past Medical History: Previous encounters with injury can shape how current injuries are perceived and managed.
- Biological Factors:
- While the model expands beyond purely biological determinants, the physical health and characteristics, like chronic medical conditions, still play a role.
- Behavioral Factors:
- Lifestyle Choices: Smoking, alcohol use, and lack of physical activity can slow recovery.
- Adherence to Treatment: Complying with rehabilitation exercises and medical advice is crucial for timely recovery.
These factors intertwine, making each case unique. Recognizing and addressing these elements early in the treatment process can be key to facilitating a more efficient and effective recovery.
The Solution
But how can the typical occmed practice/work comp doc possibly address or even determine which of the myriad factors are at play in any individual patient?
Michael Stack, CEO of Amaxx and www.reduceyourworkerscomp.com explains:
What I’ve seen help in these scenarios is when the treating physician is integrated with the claims handling team. Cases like this should be triggered to be referred to a field case manager who can provide the extra care and support needed to help manage the non-physiologic findings, which are the root cause of the problems. Using Cognitive Behavior Therapy is also an effective technique in these cases. The main thing is that the patient needs additional support beyond what is reasonable for the treating physician to provide. But, the physician can be a significant ally to the claims team to help identify these type of cases and trigger early intervention for additional support. A care coordinator, as we’ve talked about, could play this role and send a note to the adjuster of findings.
I have a course called How to Use Nurse Case Management to Improve Outcomes and Lower Workers’ Comp Costs and another titled “How to Identify Early Indicators of Creeping Catastrophic WC Claims.” Both of these touch on these subjects and could be helpful for some of your physicians to better understand the claims side and how they can leverage their role as part of the team.
The OccMarket
For our part at NAOHP, adopting the biopsychosocial model and Total Worker Health® is integral to our OccMarket platform, creating the connections between physicians/APPs, employers, claims adjusters, case/risk managers, and the injured worker, identifying the triggers to set in motion the additional support required to effectively manage the case as described above.
The OccMarket Platform
- Leverage our data-driven tools to build deeper relationships with local businesses, provide proactive injury prevention strategies, and deliver exceptional care.
- Our software equips you with the tools needed to analyze injury data, benchmark performance, and present compelling value propositions to both existing clients and new prospects.
- NAOHP members can enhance their services and generate additional revenue by offering additional value to employer clients. Offer integrated injury tracking and monitoring to your clients while generating additional revenue for your practice.
Key Benefits of OccMarket Injury Management for NAOHP Members
- Proven 7-Step Injury Management Process: Streamline injury management from initial reporting to return to work in a simple, easy-to-follow process.
- Comprehensive Compliance Tools: Help employers manage OSHA compliance and First Report of Injury seamlessly with automated reminders and data synchronization.
- Advanced Training Modules: Equip your team with the necessary skills through customized training tailored to each role’s responsibilities.
